19 January 2017

Integrating Telemedicine Responsibly

Providers and patients alike view telemedicine as an increasingly important healthcare delivery modality. Per a recent article in Medical Economics, “How to balance telemedicine advances with ethics,” the American Telemedicine Association (ATA) reports that more than half of all U.S. hospitals use some form of telemedicine; and IHS Technology predicts the number of patients using telehealth services will jump from fewer than 350,000 in 2013 to 7 million in 2018.

But this modality can also be challenging to implement responsibly.

Telehealth Benefits

The dramatic growth of telemedicine is driven by its ability to further the goals of the “quadruple aim” framework for value-based care.

More Efficient Care

The recent American Hospital Association (AHA) issue brief on telehealth cited several examples of significant telehealth-driven savings, including the Veterans Health Administration’s “nearly $1 billion in system-wide savings associated with the use of telehealth in 2012.” A major contributor was the dramatic decrease in hospitalizations.

In addition, doctors who offer telehealth services can spend more time caring for additional patients – time that otherwise would have been spent traveling between offices or facilities.

Better Outcomes

The AHA brief also describes the efficiencies and improved outcomes resulting from the innovative Hospital at Home (HaH) care model developed by Johns Hopkins researchers. HaH is being used effectively to provide hospital-level care at home in place of acute hospital care for older adults. Per the brief, “When a patient is treated at home, clinical staff travel to the home as needed to provide treatment, while telehealth is used to monitor the patient’s condition and enable daily meetings with the physician.” According to the program’s website, HaH patients experience better clinical outcomes, higher patient and family satisfaction, reduced caregiver stress and better functional outcomes compared to similar hospitalized patients.

Expanded Access to Care

Traveling to medical facilities can be a hardship for people who are physically challenged/housebound, live far from the nearest medical center or cannot afford to take time off from work. The ability to meet with a clinician remotely via a secure audiovisual device or application can mean the difference between those patients seeking – and getting – the care they need versus going without.

More Convenient Care

While it’s early days yet, “virtual visits” are beginning to be offered for more and more types of medical care. For example, St. Vincent Heart Center in Indianapolis is piloting a telecardiology program, per a recent article in Cardiovascular Business.

There is also increasing demand by health care consumers for “at home” virtual visits. A recent ATA-WEGO Health survey of active health care users found that consumers are very interested in using telehealth to complement (or even replace) their in-person care, primarily because of convenience. Other commonly cited reasons included scheduling conflicts and issues with transportation. 

Expanded Access to Specialized Clinical Expertise

Many small or rural hospitals often don’t have the budget or volume to support staffing a range of staff specialists or subspecialists. Even hospitals that have the budget may be in areas that make it difficult to recruit those types of physicians.

Dr. Lynn Palmeri, National Medical Director of Telehealth for Sheridan’s Women’s and Children’s Division, explains that telehealth carts can allow doctors at these facilities to consult remotely with specialists or subspecialists as needed. For example, an obstetrician may see an expectant mother with high-risk findings that require her to be referred out to see a perinatologist. Rather than having the mother drive three or four hours to the nearest perinatologist – potentially putting her and her baby at even greater risk – the obstetrician could have a remote telehealth consult with the subspecialist to determine whether the mother can be given appropriate care locally with the help of follow-up telehealth consults with the perinatologist.

Telemedicine is equally valuable in emergency medicine. Physicians in the adult emergency department (ED) at Jupiter Medical Center consult remotely with neurologists at the Cleveland Clinic using a telehealth cart approximately 10–30 times per month, most often to expedite implementation of tissue plasminogen activator (tPA) therapy for stroke patients.

Sophisticated telemedicine robots can allow remote specialists and subspecialists to perform much more in-depth examinations. Dr. Palmeri says “there are robots with sensors that can, for example, allow a neonatologist to remotely inspect a patient, auscultate bowel, breath and heart sounds, examine a neonate’s eyes for retinal findings, and even palpate to see if there is abdominal pathology or edema. These patient care modalities augment the in-person physical examinations by the nurse and neonatal nurse practitioner at the bedside.”

Radiology’s many subspecialties make it a prime candidate for expanding access to highly specialized clinical expertise remotely while also increasing efficiency. For example, Sheridan’s distributed teleradiology network includes hundreds of the country’s best radiology subspecialists who can provide hospitals of any size with affordable, 24/7/365 coverage and faster turnaround times for final reads. 

Challenges to Responsible Implementation

The promise of telemedicine is exciting, and pertinent logistical and quality matters will be ensured prior to its implementation and expansion.

Protecting Patient Privacy

Maintaining patient confidentiality is a cornerstone of ethical medical practice. Telemedicine systems will be HIPAA-compliant and hospitals must make data security a top criterion when selecting robot cart and software options.

Maintaining Care Quality

The same standards of care must be maintained regardless of the delivery modality, and that’s a key challenge of telemedicine. The American Medical Association (AMA) released its Guidance for Ethical Practice in Telemedicine in June. In the policy announcement, AMA Board Member Jack Resneck, M.D. said, "Telehealth and telemedicine are another stage in the ongoing evolution of new models for the delivery of care and patient-physician interactions. The new AMA ethical guidance notes that while new technologies and new models of care will continue to emerge, physicians' fundamental ethical responsibilities do not change.” The AMA also released its Principles to Promote Safe, Effective mHealth Applications in November. 

Telemedicine can make continuity of care challenging, especially when patients seek care from doctors who are not affiliated with their primary care physicians or who use different EHRs. But in some situations telehealth can improve care continuity. “In a pediatric unit, for example, an attending physician might see the baby during morning rounds, but by the time the parents can come to the hospital that evening after work that physician’s shift may have ended and the parents may not speak directly to that same doctor,” explains Dr. Palmeri. “Telemedicine has the potential to overcome those types of scheduling conflicts so that parents can speak with the doctor ‘face-to-face’ through the telemedicine robot screen whenever needed.”

Telehealth will play an increasingly important role in care delivery and physicians will carefully adopt remote care technology in a manner that ensures patient safety and privacy.